Case Study of Apparent Failures of Governance

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There is an award process for excellence in social accountability by a medical school that is organised through the ASPIRE project under the auspices of the Association for Medical Education in Europe (AMEE).

The process involves a medical school submitting an application to reviewers on a social accountability panel. The chair of the panel makes recommendations for the award to the ASPIRE board. Recent events suggest there are apparent failures of governance in relation to the work of the social accountability panel and the ASPIRE board.

I was a reviewer on the ASPIRE project’s social accountability panel from July 2011 until earlier this month. Hence I have been involved in assessing applications from medical schools for excellence in social accountability since the ASPIRE project began. As a result of expressing my concerns this year about apparent failures of governance, the executive committee of the ASPIRE board removed me from the panel.

The events that led me to express my concerns included:

In 2015 the social accountability panel recommended that no awards should be given and that led to discussions between a member of the ASPIRE board and the panel chair about obtaining further information from some applicant school. Further information was obtained but no awards were recommended. Such discussions had not occurred in previous years with the social accountability panel.

Was the board seeking to influence the recommendations of the social accountability panel?

In 2016, there was (1) low inter-reviewer reliability in some reviews: for the same criterion, different panel reviewers gave grades as far apart as 5 (definitely merits recognition of excellence) and 2 (does not merit recognition of excellence but some areas may merit commendation) yet the application was still awarded excellence.

How can excellence be justified with such low inter-reviewer reliability?

(2) low validity of some reviews: some reviewers gave grades of 5 or 4 without any justification.

What validity can be attached to these grades without a supporting narrative?

(3) panel consensus review of grade 4 (probably merits recognition of excellence): in previous years this grade meant there were insufficient areas of excellence to merit the award. However in 2016 grade 4 led to the award of excellence.

Is this not a lowering of standards by the award process?

(4) reviewers and recusance: an application from a network of schools was reviewed by a panel member who had been a former dean at one of the schools in the network. The former dean declared his former relationships with the school but neither the chair of the social accountability panel nor the executive committee of the ASPIRE board considered there could be a conflict of interest.

Why did this reviewer not recuse himself from carrying out the review?

Why did the chair of the social accountability panel or the executive committee of the ASPIRE board not require this reviewer’s recusal?

Other reviewers were available from the social accountability panel.

Declaration: I led the successful application for the award of excellence in social accountability from the Faculty of Medicine, Memorial University, Newfoundland in 2014. I recused myself from assessing that application.

It seems to me that these events offer a case study of apparent failures of governance in the award processes for excellence in social accountability by a medical school.

Why would a medical school, or veterinary school, or dental school, invest resources to submit an application and pay the application fee of £2,500 (C$4,500) in the hope of receiving an award with such apparent failures of governance?

Overall these events in 2015 and 2016 have led me to believe that some people in the ASPIRE hierarchy are not concerned about any lowering of standards because their principal interest appears to be to give awards for excellence. Giving awards for excellence would make the ASPIRE initiative appear successful even if standards have been lowered to enable the awards to be given.

I have been heartened by support from some members of the social accountability panel. Their support reminded me of Edmund Burke’s phrase in ‘Thoughts on the Cause of the Present Discontents’ (1770) – “When bad men combine, the good must associate; else, they will fall, one by one, an unpitied sacrifice in a contemptible struggle”.

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About Iain Robbe

I am a medical practitioner (MB, BS, 1980) registered with the General Medical Council of the United Kingdom without a licence to practice. I am now in practice as a Clinical Medical Educationist partly through my links with Memorial University, Newfoundland where I have an appointment as a Clinical Assistant Professor (part-time); and with the Centre for Medical Education, Dundee University where I have an appointment as an Outwith Clinical Tutor (part-time).

Also, I have links with the seven UK veterinary schools particularly for undergraduate and post graduate teaching and research in professionalism, ethics, communications, and using the arts and humanities in veterinary education.

I have a Master’s degree in Public Health from the University of London (1985) and a Master’s degree in Medical Education with distinction from the University of Wales (2001).

The guiding principles in my practices are based on andragogy and humanism, and the prime ethical principle of autonomy for the individual and in population health.

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